From the Guidelines
The management approach for stroke in a young woman should prioritize prompt evaluation, immediate brain imaging, and appropriate acute interventions, such as IV thrombolysis with alteplase for eligible ischemic stroke patients within 4.5 hours of symptom onset, as recommended by the most recent guidelines 1.
Key Considerations
- Initial management includes immediate brain imaging (CT or MRI) to distinguish between ischemic and hemorrhagic stroke, followed by appropriate acute interventions, as outlined in the 2023 systematic review and synthesis of global stroke guidelines 1.
- For young women specifically, additional investigation into unique risk factors is essential, including evaluation for patent foramen ovale, arterial dissection, thrombophilias, autoimmune disorders (particularly antiphospholipid syndrome), oral contraceptive use, pregnancy-related complications, and migraine with aura.
- Secondary prevention typically includes antiplatelet therapy or anticoagulation depending on stroke etiology, as well as addressing modifiable risk factors such as smoking cessation, blood pressure control, lipid management, and diabetes control.
Acute Management
- IV thrombolysis with alteplase is recommended for selected patients who can be treated within 4.5 hours of ischemic stroke symptom onset or last known well, with a dose of 0.9 mg/kg, maximum dose 90 mg over 60 minutes, and initial 10% of dose given as bolus over 1 minute 1.
- Patients with acute hypertension who are otherwise eligible for IV thrombolysis should have their BP lowered below 185/110 mm Hg before IV thrombolysis is initiated 1.
- Eligible patients should receive IV thrombolysis even if mechanical thrombectomy is being considered, and responses to IV thrombolysis should not be evaluated before proceeding with catheter angiography for mechanical thrombectomy 1.
Rehabilitation and Support
- Rehabilitation services should be initiated early, and psychological support is important as young stroke survivors often face unique challenges with career, family planning, and long-term disability concerns.
- Women taking estrogen-containing contraceptives who experience stroke should have these medications discontinued and alternative contraception methods considered, as suggested by previous studies 1.
From the Research
Management Approach for Stroke in a Young Woman
The management approach for a stroke in a young woman involves several key considerations, including:
- Evaluation and diagnosis of ischemic stroke in the emergency department, taking into account sex-specific risk factors and broad differentials 2
- Identification of risk factors, such as oral contraceptive use, migraine with aura, and pregnancy or postpartum period 2, 3
- Use of thrombolytic agents, such as tissue plasminogen activator, in both pregnant and nonpregnant individuals 2
- Consideration of unique challenges in the evaluation and diagnosis of ischemic stroke in young women, including a wider range of risk factors and causes compared to older patients 4, 3
Risk Factors and Causes
Some of the key risk factors and causes of ischemic stroke in young women include:
- Oral contraceptive use 2, 3
- Migraine with aura 2
- Pregnancy or postpartum period 2, 3
- Hypertension 4
- Cardioembolism 4
- Large artery athero-thromboembolism 4
- Extracranial dissection 4
- Cerebral amyloid angiopathy 4
- Arteriolosclerosis 4
Treatment Options
Treatment options for ischemic stroke in young women may include:
- Thrombolysis with tissue plasminogen activator 2, 5
- Endovascular therapy 5
- Anticoagulant therapy, such as apixaban, for stroke prevention in atrial fibrillation 6
- Management of underlying risk factors, such as hypertension and diabetes 4, 3
Prognosis and Outcomes
The prognosis and outcomes for young women with ischemic stroke are influenced by a range of factors, including: